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public employees health program, hra claims. 560 east 200 south suite 100, salt lake city, utah 84102-2004. please allow 2 business days from our receipt of your claim form when submitting claims for ebc hra expenses: claim the full eligible amount. you can also submit claims and upload receipts online by visiting and logging into the. only one patient can be listed on a claim form (multiple providers can be listed for be accumulated before you submit a claim, unless the balance in your hra. the undersigned participant in the plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided. employer name: employee name: ss#:_x_x_x_-_x_x_-. (please see instructions on reverse side). health reimbursement arrangement (hra) claim form. this form may be submitted by email, mail or fax. instructions on where to send the form are included, basic hra login, hra claim form template , hra claim form template, ebc flex forms, hra forms, ebcflex eligible expenses, hra form download , hra form download, health risk assessment forms, hra reimbursement claim form , hra reimbursement claim form
A hra claim form Word template can contain formatting, styles, boilerplate text, macros, headers and footers, as well as custom dictionaries, toolbars and AutoText entries. It is important to define styles beforehand in the sample document as styles define the appearance of text elements throughout your document and styles allow for quick changes throughout your hra claim form document.